Digital dashboards for direct oral anticoagulant surveillance, intervention and operational efficiency: uptake, obstacles, and opportunities.

Direct oral anticoagulants (DOAC) are the most widely prescribed oral anticoagulants in the United States. Despite advantages over warfarin, system-level improvements are needed to optimize outcomes. While Veterans Health Administration and others have described successful DOAC management dashboard implementation, the extent of use nationally is unknown. A survey of Anticoagulation Forum's members was conducted to assess access to digital tools available within a dashboard and to describe implementation models. An Expert Forum was subsequently convened to identify barriers to dashboard development and adoption. Responses were received from 340 targeted recipients (8.5% of invitees). Only a minority of inpatient (25/52, 48.1%) and outpatient (47/133, 35.3%) respondents outside of Veterans Health Administration were able to generate rosters of DOAC users on-demand, and fewer had the ability to digitally display key clinical data elements, identify drug-related problems, document interventions, or generate reports. The lack of regulatory requirements regarding Anticoagulation Stewardship was identified by the Expert Forum as the major barrier to widespread development of digital tools for improved anticoagulation management. While some health systems have demonstrated the feasibility of DOAC dashboards and described their impact on quality and efficiency, these tools do not appear to be widely available in the United States apart from Veterans Health Administration. The lack of regulatory requirements for Anticoagulation Stewardship may be the primary barrier to the development of digital resources to better manage anticoagulants. Efforts to secure regulatory requirements for Anticoagulation Stewardship are needed, and evidence of improvements in clinical and financial outcomes through DOAC dashboard use will likely bolster such efforts.

Digital dashboards for oral anticoagulation management: a literature scoping review.

This scoping review summarizes the extent and characteristics of the published literature describing digital population management dashboards implemented to improve the quality of anticoagulant management. A standardized search protocol was executed to identify relevant manuscripts published between January 1, 2015 and May 31, 2022. The resulting records were systematically evaluated by multiple blinded reviewers and the findings from selected papers were evaluated and summarized. Twelve manuscripts were identified, originating from 5 organizations within the US and 2 from other countries. The majority (75%) described implementation in the outpatient setting. The identified papers described a variety of positive results of dashboard use, including a 24.5% reduction of questionable direct oral anticoagulant dosing in one organization, a 33.3% relative improvement in no-show appointments in an ambulatory care clinic, and a 75% improvement in intervention efficiency. One medical center achieved a 98.4% risk-appropriate venous thromboembolism risk prophylaxis prescribing rate and 40.6% reduction in anticoagulation-related adverse event rates. The manuscripts primarily described retrospective findings from single-center dashboard implementation experiences. Digital dashboards have been successfully implemented to support the anticoagulation of acute and ambulatory patients and available manuscripts suggest a positive impact on care-related processes and relevant patient outcomes. Prospective studies are needed to better characterize the implementation and impact of dashboards for anticoagulation management. Published reports suggest that digital dashboards may improve the quality, safety, and efficiency of anticoagulation management. Additional research is needed to validate these findings and to understand how best to implement these tools.

Thromboembolic prevention and anticoagulant therapy during the COVID-19 pandemic: updated clinical guidance from the anticoagulation forum.

Thromboembolism is a common and deadly consequence of COVID-19 infection for hospitalized patients. Based on clinical evidence pre-dating the COVID-19 pandemic and early observational reports, expert consensus and guidance documents have strongly encouraged the use of prophylactic anticoagulation for patients hospitalized for COVID-19 infection. More recently, multiple clinical trials and larger observational studies have provided evidence for tailoring the approach to thromboprophylaxis for patients with COVID-19. This document provides updated guidance for the use of anticoagulant therapies in patients with COVID-19 from the Anticoagulation Forum, the leading North American organization of anticoagulation providers. We discuss ambulatory, in-hospital, and post-hospital thromboprophylaxis strategies as well as provide guidance for patients with thrombotic conditions who are considering COVID-19 vaccination.

Survival time and search time in water: Past, present and future.

The prediction of survival time for those immersed in water remains a key element in the function of search and rescue organisations around the globe. The data on which such predictions are made come from laboratory studies and actual incidents. The UK National Immersion Incident Survey (UKNIIS) represents one of the largest surveys undertaken in this area. The UKNIIS data are obtained by questionnaire from immersion incidents around the British Isles. The survey has been in operation since 1991 and at the time of writing contained almost 1600 cases. The aim of the present work was to analyse these cases with the aim of establishing a model for the prediction of survival time in water. This analysis is described in this paper: two model approaches are presented and their strengths and weaknesses are discussed. Recommendations for the use and development of such models are made.

Working smarter, not harder: evaluating a population health approach to anticoagulation therapy management.

Inappropriate direct acting oral anti-coagulants (DOAC) prescribing increases the risk of adverse events. Population health management tools (PMTs) could help reduce adverse events through the early, efficient identification of questionable prescribing practices, but the impact of such a tool remains unknown. We evaluated the effect of PMT use on questionable DOAC dosing rates within 40 VHA medical centers and whether this effect differed by DOAC indication or agent. Medical centers were divided into PMT user or standard of care (SOC) groups based upon high or low tool access in the prior year. Questionable DOAC dosing rate was defined as the proportion of patients prescribed DOACs who were also flagged by the tool. Chi-square tests were used to determine if PMT user versus SOC groups differed with high (above 15.3%) versus low (below 15.3%) questionable dosing rates. T-tests were used to determine if mean questionable dosing rates significantly differed between the PMT user and SOC groups. DOAC PMT users were classified less frequently as being 'High" questionable dosage rate compared to SOCs (25% PMT vs. 75% SOC, respectively, p = 0.002). DOAC PMT utilization within the overall cohort was associated with a 4.3% absolute reduction in questionable DOAC dosing rates (13.2% PMT vs 17.5% SOC; p = 0.01). Tool use within the atrial fibrillation (AF) subgroup was associated with a 5.1% absolute reduction in questionable dosing rates (10.4% SOC vs. 5.3% PMT, p < 0.001). Tool use was also associated with lower questionable dosing rates in the apixaban (p < 0.001), dabigatran (p = 0.03) and AF plus venous thromboembolism (p < 0.001) subgroups. In our study, PMT use was associated with reduced questionable DOAC dosing, a difference most pronounced within AF patients. A population health approach has the potential to reduce adverse events among patients prescribed DOACs.

Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the anticoagulation forum.

Coronavirus disease 2019 (COVID-19) is a viral infection that can, in severe cases, result in cytokine storm, systemic inflammatory response and coagulopathy that is prognostic of poor outcomes. While some, but not all, laboratory findings appear similar to sepsis-associated disseminated intravascular coagulopathy (DIC), COVID-19- induced coagulopathy (CIC) appears to be more prothrombotic than hemorrhagic. It has been postulated that CIC may be an uncontrolled immunothrombotic response to COVID-19, and there is growing evidence of venous and arterial thromboembolic events in these critically ill patients. Clinicians around the globe are challenged with rapidly identifying reasonable diagnostic, monitoring and anticoagulant strategies to safely and effectively manage these patients. Thoughtful use of proven, evidence-based approaches must be carefully balanced with integration of rapidly emerging evidence and growing experience. The goal of this document is to provide guidance from the Anticoagulation Forum, a North American organization of anticoagulation providers, regarding use of anticoagulant therapies in patients with COVID-19. We discuss in-hospital and post-discharge venous thromboembolism (VTE) prevention, treatment of suspected but unconfirmed VTE, laboratory monitoring of COVID-19, associated anticoagulant therapies, and essential elements for optimized transitions of care specific to patients with COVID-19.

Impact of a Direct Oral Anticoagulant Population Management Tool on Anticoagulation Therapy Monitoring in Clinical Practice.

Background: The optimal monitoring and follow-up strategy for long-term direct oral anticoagulant (DOAC) therapy has not been established. Historically, at our medical center, DOAC patients were referred to a clinical pharmacy specialist managed anticoagulation clinic (AC) for monitoring via regularly scheduled encounters (face-to-face or telephone). Objective: To determine if implementation of a DOAC Population Management Tool (PMT) designed to identify patients who most likely require clinical review and possibly intervention, would improve the efficacy (interventions per patient) and efficiency (time invested to generate an intervention) of monitoring over AC practices. Methods: The DOAC PMT group included patients flagged as potentially having a dosing issue or history of valve replacement. The AC group included patients who were scheduled for routine DOAC follow-up. The quantity and character of interventions made were prospectively recorded and compared. Results: A total of 399 patients were included. Data were collected for 131 patients identified by the DOAC PMT, resulting in a review of 170 flags with a total of 94 interventions or 0.55 interventions per flag reviewed. For the AC group, 268 patients were evaluated, leading to 53 interventions or 0.20 interventions per patient encounter (P < 0.001 for comparison). The time to generate an intervention was 16 minutes in the DOAC PMT versus 64 minutes for the AC group. Conclusion and Relevance: A population-based approach to DOAC monitoring represents a more effective and efficient strategy to reduce missed opportunities for interventions between follow-up appointments while also increasing clinic access, particularly for patients who require immediate attention.

Results of a Regional Effort to Improve Warfarin Management.

BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

Urea Release by Intermittently Saturated Sediments from a Coastal Agricultural Landscape.

Urea-N is linked to harmful algal blooms in lakes and estuaries, and urea-N-based fertilizers have been implicated as a source. However, the export of urea-N-based fertilizers appears unlikely, as high concentrations of urea-N are most commonly found in surface waters outside periods of fertilization. To evaluate possible autochthonous production of urea-N, we monitored urea-N released from drainage ditch sediments using mesocosms. Sediments from a cleaned (recently dredged) drainage ditch, uncleaned ditch, forested ditch, riparian wetland, and an autoclaved sand control were isolated in mesocosms and flooded for 72 h to quantify urea-N, NH-N, and NO-N in the floodwater. Sediments were flooded with different N-amended solutions (distilled HO, 1.5 mg L NH-N, 3.0 mg L NH-N, 2.6 mg L NO-N, or 5.1 mg L NO-N) and incubated at three water temperatures (16, 21, and 27°C). Urea-N concentrations in mesocosms representing uncleaned and cleaned drainage ditches were significantly greater than nonagricultural sediments and controls. While flooding sediments with N-enriched solution had no clear effect on urea-N, warmer (27°C) temperatures resulted in significantly higher urea-N. Data collected from field ditches that were flooded by a summer rainstorm showed increases in urea-N that mirrored the mesocosm experiment. We postulate that concentrations of urea-N in ditches that greatly exceed environmental thresholds are mediated by biological production in sediments and release to stagnant surface water. Storm-driven urea-N export from ditches could elevate the risk of harmful algal blooms downstream in receiving waters despite the dilution effect.

Persistence and Surface Transport of Urea-Nitrogen: A Rainfall Simulation Study.

Studies of harmful algal blooms and associated urea concentrations in the Chesapeake Bay and in coastal areas around the globe strongly suggest that elevated urea concentrations are associated with harmful algal blooms. The observed increased frequency and toxicity of these blooms in recent decades has been correlated with increased agricultural use of N inputs and increased use of urea as a preferred form of commercial N. This rainfall simulation study sought to assess the potential for different N fertilizers and manures to contribute to urea in runoff from a Coastal Plain soil on the Eastern Shore of Maryland. Under worst-case conditions, ~1% of urea-N applied as commercial fertilizer and surface-applied poultry litter was lost in runoff in a simulated rainfall event, roughly equivalent to a 1-yr return period rain storm in the study area, 12 h after application. Cumulative urea-N losses, including four subsequent weekly rainfall events, approached 1.7% from urea-N fertilizer containing a urease inhibitor. Urea-N loss from incorporated poultry litter was negligible, and losses from dairy manure were intermediate. These losses are likely confined to hydrological contributing areas that extend several meters from a drainage ditch or stream for storms with frequent recurrence intervals. Cumulative dissolved N losses in runoff (urea-N + ammonium-N + nitrate-N) as a proportion of total applied plant-available N were <5%, suggesting that most of the applied N was lost by other pathways or was immobilized in soil. Results also highlight the potential for simple management options, such as shallow incorporation or timing, to greatly reduce urea runoff losses.

Phosphorus leaching from agricultural soils of the delmarva peninsula, USA.

Leaching of phosphorus (P) mobilizes edaphic and applied sources of P and is a primary pathway of concern in agricultural soils of the Delmarva Peninsula, which defines the eastern boundary of the eutrophic Chesapeake Bay. We evaluated P leaching before and after poultry litter application from intact soil columns (30 cm diameter × 50 cm depth) obtained from low- and high-P members of four dominant Delmarva Peninsula soils. Surface soil textures ranged from fine sand to silt loam, and Mehlich-3 soil P ranged from 64 to 628 mg kg. Irrigation of soil columns before litter application pointed to surface soil P controls on dissolved P in leachate (with soil P sorption saturation providing a stronger relationship than Mehlich-3 P); however, strong relationships between P in the subsoil (45-50 cm) and leachate P concentrations were also observed ( = 0.61-0.73). After poultry litter application (4.5 Mg ha), leachate P concentrations and loads increased significantly for the finest-textured soils, consistent with observations that well-structured soils have the greatest propensity to transmit applied P. Phosphorus derived from poultry litter appeared to contribute 41 and 76% of total P loss in leachate from the two soils with the finest textures. Results point to soil P, including P sorption saturation, as a sound metric of P loss potential in leachate when manure is not an acute source of P but highlight the need to factor in macropore transport potential to predict leaching losses from applied P sources.

Phosphorus and nitrogen leaching before and after tillage and urea application.

Leaching of nutrients through agricultural soils is a priority water quality concern on the Atlantic Coastal Plain. This study evaluated the effect of tillage and urea application on leaching of phosphorus (P) and nitrogen (N) from soils of the Delmarva Peninsula that had previously been under no-till management. Intact soil columns (30 cm wide × 50 cm deep) were irrigated for 6 wk to establish a baseline of leaching response. After 2 wk of drying, a subset of soil columns was subjected to simulated tillage (0-20 cm) in an attempt to curtail leaching of surface nutrients, especially P. Urea (145 kg N ha) was then broadcast on all soils (tilled and untilled), and the columns were irrigated for another 8 wk. Comparison of leachate recoveries representing rapid and slow flows confirmed the potential to manipulate flow fractions with tillage, albeit with mixed results across soils. Leachate trends in the finer-textured soil suggest that tillage impeded macropore flow and forced greater matrix flow. Despite significant vertical stratification of soil P that suggested tillage could prevent leaching of P via macropores from the surface to the subsoil, tillage had no significant impact on P leaching losses. Relatively high levels of soil P below 20 cm may have served as the source of P enrichment in leachate waters. However, tillage did lower losses of applied urea in leachate from two of the three soils, partially confirming the study's premise that tillage would destroy macropore pathways transmitting surface constituents to the subsoil.

Nationwide Implementation of a Population Management Dashboard for Monitoring Direct Oral Anticoagulants: Insights From the Veterans Affairs Health System.

BACKGROUND: Direct oral anticoagulants are first-line therapy for common thrombotic conditions, including atrial fibrillation and venous thromboembolism. Despite their strong efficacy and safety profile, evidence-based prescribing can be challenging given differences in dosing based on indication, renal function, and drug-drug interactions. The Veterans Health Affairs developed and implemented a population management dashboard to support pharmacist review of anticoagulant prescribing. The dashboard includes information about direct oral anticoagulants and dose prescribed, renal function, age, and weight, potential interacting medications, and the need for direct oral anticoagulant medication refills. It is a stand-alone system. METHODS: Using login data from the dashboard, nationwide implementation was evaluated using elements from the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS: Between August 2016 and June 2020, 150/164 sites within the Veterans Health Affairs system used the dashboard, averaging 1875 patients per site. The dashboard was made available to sites on a staggered basis. Moderate or high adoption, defined as at least one login on at least 2 separate days per month, began slowly with 3/5 sites in the pilot phase but rapidly grew to 142/150 (94.7%) sites by June 2020. The average number of unique users per site increased from 2.4 to 7.5 over the study period. Moderate to high adoption of the dashboard's use was maintained for > 6 months in 126/150 (84.0%) sites by the end of the study period. CONCLUSIONS: There was rapid and sustained implementation and adoption of a population health dashboard for evidence-based anticoagulant prescribing across the national United States Veterans Health Administration health system. The impact of this tool on clinical outcomes and strategies to replicate this care model in other health systems will be important for broad dissemination and uptake.

Role of Individual Clinician Authority in the Implementation of Informatics Tools for Population-Based Medication Management: Qualitative Semistructured Interview Study.

BACKGROUND: Direct oral anticoagulant (DOAC) medications are frequently associated with inappropriate prescribing and adverse events. To improve the safe use of DOACs, health systems are implementing population health tools within their electronic health record (EHR). While EHR informatics tools can help increase awareness of inappropriate prescribing of medications, a lack of empowerment (or insufficient empowerment) of nonphysicians to implement change is a key barrier. OBJECTIVE: This study examined how the individual authority of clinical pharmacists and anticoagulation nurses is impacted by and changes the implementation success of an EHR DOAC Dashboard for safe DOAC medication prescribing. METHODS: We conducted semistructured interviews with pharmacists and nurses following the implementation of the EHR DOAC Dashboard at 3 clinical sites. Interview transcripts were coded according to the key determinants of implementation success. The intersections between individual clinician authority and other determinants were examined to identify themes. RESULTS: A high level of individual clinician authority was associated with high levels of key facilitators for effective use of the DOAC Dashboard (communication, staffing and work schedule, job satisfaction, and EHR integration). Conversely, a lack of individual authority was often associated with key barriers to effective DOAC Dashboard use. Positive individual authority was sometimes present with a negative example of another determinant, but no evidence was found of individual authority co-occurring with a positive instance of another determinant. CONCLUSIONS: Increased individual clinician authority is a necessary antecedent to the effective implementation of an EHR DOAC Population Management Dashboard and positively affects other aspects of implementation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13012-020-01044-5.

Using flue gas desulfurization gypsum to remove dissolved phosphorus from agricultural drainage waters.

High levels of accumulated phosphorus (P) in soils of the Delmarva Peninsula are a major source of dissolved P entering drainage ditches that empty into the Chesapeake Bay. The objective of this study was to design, construct, and monitor a within-ditch filter to remove dissolved P, thereby protecting receiving waters against P losses from upstream areas. In April 2007, 110 Mg of flue gas desulfurization (FGD) gypsum, a low-cost coal combustion product, was used as the reactive ingredient in a ditch filter. The ditch filter was monitored from 2007 to 2010, during which time 29 storm-induced flow events were characterized. For storm-induced flow, the event mean concentration efficiency for total dissolved P (TDP) removal for water passing through the gypsum bed was 73 ± 27% confidence interval (α = 0.05). The removal efficiency for storm-induced flow by the summation of load method was 65 ± 27% confidence interval (α = 0.05). Although chemically effective, the maximum observed hydraulic conductivity of FGD gypsum was 4 L s(-1), but it decreased over time to <1 L s(-1). When bypass flow and base flow were taken into consideration, the ditch filter removed approximately 22% of the TDP load over the 3.6-yr monitoring period. Due to maintenance and clean-out requirements, we conclude that ditch filtration using FGD gypsum is not practical at a farm scale. However, we propose an alternate design consisting of FGD gypsum-filled trenches parallel to the ditch to intercept and treat groundwater before it enters the ditch.

Phosphorus runoff losses from subsurface-applied poultry litter on coastal plain soils.

The application of poultry litter to soils is a water quality concern on the Delmarva Peninsula, as runoff contributes P to the eutrophic Chesapeake Bay. This study compared a new subsurface applicator for poultry litter with conventional surface application and tillage incorporation of litter on a Coastal Plain soil under no-till management. Monolith lysimeters (61 cm by 61 cm by 61 cm) were collected immediately after litter application and subjected to rainfall simulation (61 mm h(-1) 1 h) 15 and 42 d later. In the first rainfall event, subsurface application of litter significantly lowered total P losses in runoff (1.90 kg ha(-1)) compared with surface application (4.78 kg ha(-1)). Losses of P with subsurface application were not significantly different from disked litter or an unamended control. By the second event, total P losses did not differ significantly between surface and subsurface litter treatments but were at least twofold greater than losses from the disked and control treatments. A rising water table in the second event likely mobilized dissolved forms of P in subsurface-applied litter to the soil surface, enriching runoff water with P. Across both events, subsurface application of litter did not significantly decrease cumulative losses of P relative to surface-applied litter, whereas disking the litter into the soil did. Results confirm the short-term reduction of runoff P losses with subsurface litter application observed elsewhere but highlight the modifying effect of soil hydrology on this technology's ability to minimize P loss in runoff.

Shifting the Paradigm: A Population Health Approach to the Management of Direct Oral Anticoagulants.

Over the past decade, direct oral anticoagulants (DOACs) have contributed to a major paradigm shift in thrombosis management, replacing vitamin K antagonists as the most commonly prescribed anticoagulants in many countries. While DOACs provide distinct advantages over warfarin (eg, convenience, simplicity, and safety), they are frequently associated with inappropriate prescribing and adverse events. These events have prompted regulatory agencies to mandate oversight, which individual institutions may find difficult to comply with given limited resources. Veterans Health Administration (VHA) has leveraged technology to develop the DOAC Population Management Tool (PMT) to address these challenges. This tool has empowered VHA to update a 60-year standard of care from one-to-one provider-to-patient anticoagulation monitoring to a population-based management approach. The DOAC PMT allows for the oversight of all patients prescribed DOACs and leads to intervention only when clinically indicated. Using the DOAC PMT, facilities across VHA have maximized DOAC oversight while minimizing resource usage. Herein, we discuss how the DOAC PMT was conceived, developed, and implemented, along with the challenges encountered throughout the process. Additionally, we share the impact of the DOAC PMT across VHA, and the potential of this approach beyond anticoagulation and VHA.